Understanding Grief and Depression: Pathological Aspects

1. Affect disorders. Mask depression. Epilepsy. Etiology and pathogeny. Classification. Epileptic psychoses. Patients with changes of personality by epileptic type. Mysula Yuriy

2. Sadness • Allofushaveexperiencedsadness, theundesiredemotionwhichaccompaniesundesiredevents, suchaslossof a valuedobjectorindividual, orfailuretoachieveadesiredgoal. Whilehealthypeoplereportdayswhentheyare “a bitdown” forno • apparentreason, inhealthypeople, significantsadnessoccursonlyas a reactiontoevents. • Inthemooddisorders, themoodshiftsexcessivelyinresponsetominorevents, orautonomously, thatis, intheabsenceofstimulatingevents, andonceshiftedthepathologicalmoodpositionissustained

4. Grief • Griefisthetermappliedtotheunpleasantexperienceofhavinglost a significantotherperson. Whilethisexperiencecanresultfromthelossofinanimateobjects, suchas a valuableartworkscollectedover a lifetime, griefmostcommonlyoccurswiththelossofanindividualwhohasbeenimportantinourlives. Griefisemotionalpain, accompaniedby a longingforthereturnofthelostobject, and a feelingofloss, emptinessandincompletenes s. InWesternculturestheremaybecrying, insomniaandlossofappetite. Theremaybe a senseofguiltatbeingaliveintheabsenceoftheimportantother, andauditoryandvisualhallucinationsofthelostindividual.

6. Cultureinfluencestheexpressionandexperienceofgrief. Someculturesprescribethebehaviouranddressofthebereaved, andeventhepreciselengthofthegrieving/mourningprocess. Thedetailsvarydependingonthenatureoftherelationship (universally, spousesgrievelongerthansiblings). Thereareadvantagesofanestablishedgrievingprotocol. Thebereavedindividual, whoisdistressedandfindsmakingdecisionsdifficult, has a clearscrip turitualtofollow. Adheringtotheritualensuresnooneisoffendedduringthisemotionaltime. Also, onceallsteps/obligationshavebeenfulfilledthereis a sanctionedendtothegrieving, andthebereavedaretoreturntotheirusuallife .

8. Grief Thegriefreactionisconsideredtohavebecome “pathological” whenitpersistslongerthanusualorhasunusualfeatures (Nakamura, 1999). Thereisconcernwhenthegriefisnotabatingsomemonthsafterthedeath. Itisgenerallybelievedthegrievingprocesstakes 6 to 12 months. • Unusualfeatureswhichidentifypathologicalgriefincludedistressto a muchgreaterdegreethanisculturallysanctioned. Thebereavedindividualwhohasnoteatenorsleptandisinconsolableoneweekaftertheeventissufferingexcessively

9. SADNESS AND DEPRESSION

10. SADNESS AND DEPRESSION Whenpathologicalguiltissuspected, itisimportanttoexcludeotherdiagnosableconditions (majordepressivedisorderoranxietydisorders) whichmayhavebeentriggeredbytheloss. Alongwithgriefcounsellingandsupport, anyco -morbiddisordersshouldbetreatedinthestandardmanner. Griefandpathologicalgriefareyettobefullyelucidated. Forexample, whatdoes “recovery” meanfollowingthelossof a spouseof 50 years? Pathologicalgriefisnotlistedinthe DSM-IV.

11. Depression • Weallsuffersadnessinresponsetoundesiredeventssuchasloss. Inthissection, thosepsychiatricdisorderswillbeoutlined, inwhichthemoodischangedinthedirectionofsadness/depression . Itisimportanttobeawarethatinthesedisorders, moodchangeisnottheonlysymptom; othersincludevegetativesymptomssuchassleepandappetitechange. Thus, thesedisordersarediagnosedusingbatchesorpatternsofsymptoms. • Themaindisordersincludemajordepressivedisorder, bipolardepressionanddysthymia. Untilrecenttimesitwasconsideredthatthedepressedepisodeinmajordepressivedisorderandbipolardepressionweremuchthesame.

12. Depression • Thisisnowindoubt; certainlybipolardepressionpresentsa greaterchallengetotheclinician. Dysthymiaisdistressingcondition, butthedepthorthesadnessandimpairmentoffunctionislessseverethanmajordepressivedisorderandbipolardepression.

13. Major depressive episode A majordepressiveepisodeis a batchorpatternofsymptoms, whichisthesamefor depressivedisorderandbipolardepression. Thefinaldiagnosisofmajordepressivedisorderasopposedtobipolardepressiondependsonwhethertherehasbeenanepisodeofmania (pathologicalmoodelevation) inthepast.

14. Criteriaformajordepressiveepisode: • 1. Atleastoneofthefollowingforatleasttwoweeks: • persistentdepressedmood • lossofinterestandpleasure. • 2. Atleastfourofthefollowing: • significantweightlossorgain,insomniaorincreasedsleep, agitation (worryingandphysicalrestlessness) orretardation (slowedthinkingandmoving),fatigueorlossofenergy • feelingsofworthlessnessorinappropriateguilt • diminishedabilitytoconcentrateorindecisiveness • thoughtsofdeathorsuicide.

15. Major depressive episode • Majordepressivedisorderisdiagnosedwhenthereis/hasbeenoneormoremajordepressiveepisodesandnohistoryofmaniaorhypomania • Thisseriousdisordercausesgreatsufferingandmayendinsuicide. TheprevalenceinWesternsocietiesis 5.4 to 8.9 % (Narrowetal, 2002). A recentmodellingstudyfoundthatclosetohalfthepopulationcanexpectoneormoreepisodesofdepressionintheirlifetime (Andrewsetal, 2005). Theprevalenceofdepressivedisorderistwiceascommoninfemales. Theaverageageofonsetisinthemid -20s.

17. Major depressive episode • 80% ofpeoplewhosuffer a majordepressiveepisodewillhaverecurrentepisodes. Theclinicalcourseofdepressionisnotasfavourableaswasoncebelieved. Infact, atoneyearfollowup, only 40% ofpatientsaresymptomfree, 20% havesomeresidualsymptoms, andthefinal 40% stillhavedepressivedisorder. • About 15% ofpeoplewitheitherdepressivedisorderorbipolardisorderdiebysuicide. • Abnormalitiesin a rangeofneurotransmitterhavebeenproposed, includingserotonin,norepinephrine, dopamine, GABA, brainderivedneurotrophicfactor, somatostatin,acetylcholine, corticotropinreleasingfactor, andsubstance P.

18. Major depressive episode • Aetiology • Heritabilityofdepressionisestimatedtobeintherange 31-42% . Nosinglegeneformajoreffecthavebeenidentified. A multitudeofgeneswithsmalleffectarelikelytobeinvolved, whichinteractwithenvironmentalfactors. • Inadditiontogeneticfactors, otherriskfactorsincludeneuroticpersonalitytraits, lowself-esteem, earlyonsetanxiety, a historyofconductdisorder, substanceuse, adversity, interpersonaldifficulties, lowparentalwarmth, childhoodsexualabuse, loweduction, lifetimetrauma, lowsocialsupport , divorceandstressfullifeevents

19. Bipolar depression • Inthemid 1960’s theconclusionwasdrawnthatbipolardisorder (formerlymanicdepressivepsychosis) andmajordepressivedisorder (alsotermedunipolardepression) aredifferentdisorders

20. Bipolardepression • The depressive episodes seen in bipolar disorder, in contrast to those typically seen in a major depression, tend to come on fairly acutely, over perhaps a few weeks, and often occur without any significant precipitating factors. They tend to be characterized by psychomotor retardation, hyperphagia, and hypersomnolence and are not uncommonly accompanied by delusions or hallucinations. On the average, untreated, these bipolar depressions tend to last about a half year. • Mood is depressed and often irritable. The patients are discontented and fault-finding and may even come to loathe not only themselves but also everyone around them.

21. Bipolar depression Patients may lose interest in life; things appear dull and heavy and have no attraction. Many patients feel a greatly increased need for sleep. Some may succumb and sleep 10, 14, or 18 hours a day. Yet no matter how much sleep they get, they awake exhausted, as if they had not slept at all. Appetite may also be increased and weight gain may occur, occasionally to an amazing degree. Conversely, some patients may experience insomnia or loss of appetite.Psychomotor retardation is the rule, although some patients may show agitation. In psychomotor retardation the patient may lie in bed or sit in the chair for hours, perhaps all day, profoundly apathetic and scarcely moving at all. Speech is rare; if a sentence is begun, it may die in the speaking of it, as if the patient had not the energy to bring it to conclusion. At times the facial expression may become tense and pained, as if the patient were under some great inner constraint.

22. Bipolar depression • Pessimism and bleak despair permeate these patients' outlooks. Guilt abounds, and on surveying their lives patients find themselves the worst of failures, the greatest of sinners. Effort appears futile, and enterprises begun in the past may be abandoned. They may have recurrent thoughts of suicide, and impulsive suicide attempts may occur. • Delusions of guilt and of well-deserved punishment and persecution are common. Patients may believe that they have let children starve, murdered their spouses, poisoned the wells. Unspeakable punishments are carried out: their eyes are gouged out; they are slowly hung from the gallows; they have contracted syphilis or AIDS, and these are a just punishment for their sins.

23. Bipolar depression • Hallucinations may also appear and may be quite fantastic. Heads float through the air; the soup boils black with blood. Auditory hallucinations are more common, and patients may hear the heavenly court pronounce judgment. Foul odors may be smelled, and poison may be tasted in the food. • In general a depressive episode in bipolar disorder subsides gradually. Occasionally, however, it may come to an abrupt termination. A patient may arise one morning, after months of suffering, and announce a complete return to fitness and vitality. In such cases, a manic episode is likely to soon follow.

25. Dysthymia • In dysthymia, patients present with extremely chronic yet low-level depressive symptoms that seem to pervade their entire existence— past, present, and probably future. • Dysthymia is in3 times more frequent among females than males, and appears to be a common condition, with a lifetime prevalence of about 6%. • The fact that the vast majority of patients with dysthymia also at some point experience a full depressive episode argues for an identity between the two disorders; however, a small percentage of patients with dysthymia never experience a full depressive episode throughout their lives.

26. Dysthymia • Mood is typically depressed and sorrowful; at times some querulousness or irritability may occur. The outlook is pessimistic, even somber. Everything is taken too seriously, and life is seen as an opportunity only for toil. Though joyous occasions, such as a promotion, graduation, or the birth of a child, may temporarily lift these patients to some warmth and appreciation, they typically sink again quickly back into misery. • Self-confidence is lacking. New tasks or stresses seem hopelessly difficult, and although patients may shoulder their burdens with grim determination, in their hearts they expect only failure.Thinking is difficult. Patients may complain of feeling heavy-headed and slow and of not being able to concentrate. Irresolution is common, and decisions may be postponed, again and again.Fatigue is common, and patients may complain of feeling exhausted much of the time.Hypochondriacal concerns may appear. Patients may worry over minor headaches or gastrointestinal upset, and this may occasion numerous trips to the physician. Appetite may suffer, and some patients may lose weight. Difficulty falling asleep is common, and some patients complain of restless, broken sleep.

28. MOOD ELEVATION DISORDERS • Pathologicalmoodelevationisconceptualizedastwolevels: mania (thehighe r level), andhypomania (underorlessthanmania). Hypomanicsymptomsmayoccurinbothbipolardisorderandtheelevatedphaseofcyclothymia. Asthesearemattersofdegreeandjudgement, in a particularcase, cliniciansmaydisagreeonthemostappropriatedesignation. Thisisoflittleimportance. Theimportantissueittoidentifywhentreatmentisindicated, andtoprovidethattreatment. • Moodelevationoftenpresentswitheuphoria, disinhibitionandfriendliness

29. MOOD ELEVATION DISORDERS

30. MOOD ELEVATION DISORDERS • The DSM-IV diagnosticcriteriafor a manicepisode: • A. A distinctperiodofabnormallyandpersistentlyelevate d, expansive, or • irritablemood, lastingatleastoneweek (oranydurationifhospitalizationisnecessary). • B. Duringtheperiodofmooddisturbance, atleast 3 ofthefollowingsymptomshavepersisted (4 ifthemoodisonlyirritable) andhavebeenpresentto a significantdegree. • 1. Inflatedself-esteemandgrandiosity • 2. Decreasedneedforsleep • 3. Moretalkativethanusualorpressuretokeeptalking • 4. Flightofideasorsubjectiveexperiencethatthoughtsareracing • 5. Distractibility

32. MOOD ELEVATION DISORDERS • 6. Increaseingoal-directedactivityorpsychomotoragitation • 7. Excessiveinvolvementinpleasurableactivitieswhichhave a high • potentialforpainfulconsequences (unrestrainedbuyingsprees, sexual • indiscretions, foolishbusinessinvestments) • C. Mooddisturbancesufficientlyseveretocausemarkedimpairmentin • occupationalfunctioningorinusualsocialactivitiesorrelationshipswith • others, ortonecessitatehospitalizationtopreventharmtoselforothers.

33. Hypomanicepisode • Bydefinition, thehypomanicepisodeislessseverethanthefullmanicepisode. DSM - • IV hasattemptedtoquantifythisdifference. Itisunclearwhetherthisdistinctionishelpful. • Ratherthanbeingpresentfor 1 week, thediagnosticcriteriastatethathypomanianeedbepresentforonly 4 days. Theneedfor 3 or 4 of 7 listedsymptomsremainsunchanged. • Themaindifferenceisthat: “ Theepisodeisnotsevereenoughtocausemarkedimpairmentinsocialoroccupationalfunctioning, ortonecessitatehospitalization, andtherearenopsychoticsymptoms ”.

35. Cyclothymicdisorder • The DSM-IV diagnosticcriteriaarethatover a periodof 2 yearstherehavebeennumerousepisodesofhypomanicsymptomsandnumerousepisodesofdepressivesymptoms. Further, duringthistimeitisnotbeenpossibletomake a diagnosisofmajordepressiveepisode, manicepisodeormixedmoodstate.